Weight Loss Intake

Please complete this form before your visit so Dr. Mann can review your history in advance. Fields marked required must be filled in.

Your contact information

Full name (required)

Email (required)

Phone (required)

Intake questions

What is your current weight and height?

What is your goal weight, and do you have a timeline?

What weight loss programs or diets have you tried, and what worked?

Do you have any of these medical conditions? (check all that apply)
DiabetesThyroid issuesPCOSHigh blood pressureOther

If other, please describe.

Are you taking any medications or supplements that may affect your weight?

What is your activity level?

Describe a typical day of eating.

Do you experience emotional eating, cravings or late-night snacking?

How many meals and snacks do you have per day?

Are there foods you do not want to give up?

Privacy: Your health information is kept confidential and used only by Juvenate Medical to prepare for your visit. See our Privacy Policy.

I have read the privacy note and consent to Juvenate Medical receiving this information. (required)

Save as PDF: in the print window, choose Save as PDF as the destination.

Please do not include medical details in this form; we will discuss your health privately. See our Privacy Policy.

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